Person who will need a caregiver: Client’s First Name: Client’s Last Name: Phone: Cell Phone: Phone Type : IphoneAndroidOthers Home Address: City: State: Zip Code: Email Address: How did you find out about us? Referred from a friendReferred from a facilitySaw our StorefrontReferred by a One AgencyReferred by another AgencyFound us on the Internet Referral Name: 1st Family Contact: First Name: Last Name: Relationship: Home Address: City: State: Zip Code: Phone: Cell Phone: Phone Type : IphoneAndroidOthers Email Address: 2nd Family Contact: First Name: Last Name: Relationship: Home Address: City: State: Zip Code: Phone: Cell Phone: Phone Type : IphoneAndroidOthers Email Address: Does the patient have a long term insurance policy? YesNo If Yes: Insurance Company: Phone: Policy and/or Claim Number: Schedule Start Date: Discharge Date: Live In: YesNo Live Out:YesNo Live In Fill In:YesNo Full Time Hourly:YesNo Part Time Hourly:YesNo Hospice: YesNo We need live in 7 Days We need live in for these days only Change over time is usually around dinner time. Sunday Monday Tuesday Wednesday Thursday Friday Saturday For Live Out(Total Hours) Sunday Monday Tuesday Wednesday Thursday Friday Saturday Preferred One Agency’s Gender : FemaleMaleAny Do you need a One Agency with Driver’s License (to drive the patient to Doctor’s Appointment or grocery shopping ) YesNo If yes, Client's CarOne Agency's Car Please Note: Most hourly caregivers drive, live in caregivers generally do not drive although they typically have someone drop them off and pick them up and can usually handle the grocery shopping for the client. Live in caregivers who drive are rare and in demand, they usually request an extra $20 per day because they are a live in driver. Also, most caregivers are requesting $1 Per Mile for mileage if they are driving their own vehicle. For Live In: Do you have a bedroom for caregiver? YesNo Is there a separate bedroom? YesNo If No, what are the sleeping arrangements? Other: Is there a TV in the caregiver’s room? YesNo Is there Wi-Fi in the house? YesNo Is there a baby monitor so the caregiver can monitor the client at night? YesNo Are there pets in the home? YesNo If yes, please describe all(size also), and what responsibilities you would expect from the caregiver: Notes and Special Instructions: Client Information Date of Birth: Age: Weight: Gender: MaleFemale Height: Presenting Diagnosis: Does the client lives alone?:YesNo Household members living with the client?: Can the client walk? :with assistanceor without assistance Can the client stand? on her/his ownor with assistance Using a walkerUsing a caneUsing a wheelchairBedridden Is lifting Required? YesNo If yes, how much: Can the client push with their legs? YesNo What % pushing to pulling?: Is the client:ContinentIncontinent Does the client have: CatheterColostomyDiapersDiapers just in caseBed padsBedside commode No If the client uses diapers, is there a special receptacle for soiled diapers? YesNo Primary Physician : Secondary Physician : Special Dietary Needs:YesNo If yes, please list: Cognitive Ability:AlertOriented Dementia / Alzheimer’s:BeginningModerateAdvancedSundowners(patient is more disoriented at night) Is the client sleeping at night?YesNo How many times does the client use the bathroom between 10pm-6am? Does the client need assistance with ADL’s: YesNo (needs small meals, light housekeeping, and laundry) Personal hygiene/bathing(a shower stool with a hose attachment):YesNo Meals prepared:YesNo Laundry (fluff and fold):YesNo Has the patient ever been placed under a 5150? YesNo Does the patient have a history of strike out? YesNo Is the patient smoking? YesNo If yes, the client is smoking and/or using:CigarVape Client’s Billing Yes I would like to use your debit card. We will contact you to set up Debit Billing. If you are choosing direct pay, would you like an invoice that reflects the total expense? YesNo Invoices are generated on a weekly basis. Would you prefer? E-billSnail Mail Billing Information: Insurance Email Address Billing Address City: State: Zip Code: Most clients write checks, but if you prefer to create a re-occuring transaction. We accept Debit Card.
